Qualifications

If you are under 18 years of age, can you provide required proof of eligibility to work?

Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? (Proof of citizenship or immigration status will be required upon employment.)

Yes No

Work Availability

Full Time Part Time Temporary

Have you been convicted of a felony? (Conviction will not necessarily disqualify an applicant for employment.)

Yes No

If yes, please explain

Membership in professional or civic organizations (Exclude those which may disclose your race, color, religion or national group)

Education

High School

Address

From

To

Did you graduate?

Yes No

Degree

College

Address

From

Did you graduate?

Yes No

To

Degree

Other School/Training

Address

From

To

Did you graduate?

Yes No

Degree

Employment

Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer. Indicating “See Resume” will not be accepted.

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for leaving

Permission to contact previous employer for reference

Yes No

References

1. Full Name/Phone/Email/Relationship

2. Full Name/Phone/Email/Relationship

3. Full Name/Phone/Email/Relationship

Electronic Signature

* I agree that the information provided in the Application for Employment is true, correct, and complete. If employed, any misstatement or omission of fact on this application may result in dismissal. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. If you decide to engage an investigative consumer reporting agency to report on my credit and personal history I authorize you to do so. If report is obtained you must provide, at my request, the name and address of the agency so I may obtain from them the nature and substance of the information contained in the report.

E-Signature

Date

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About Pennyroyal Center

We are proud to be a CARF accredited agency for our Outpatient Services and Therapeutic Foster Care Programs. The Pennyroyal 24 hour RESPOND Center is also now a proud partner of the National Suicide Prevention Lifeline. Our clinical assessors are available anytime day or night. You can also text us at 839863 keyword RESPOND.